Provider Demographics
NPI:1023623881
Name:MCCARTHY, ELAINE MARY (PA)
Entity type:Individual
Prefix:
First Name:ELAINE
Middle Name:MARY
Last Name:MCCARTHY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:39 5TH ST
Mailing Address - Street 2:
Mailing Address - City:EAST HAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11937-4114
Mailing Address - Country:US
Mailing Address - Phone:631-946-2664
Mailing Address - Fax:
Practice Address - Street 1:STONY BROOK SOUTHAMPTON HOSPITAL
Practice Address - Street 2:240 MEETING HOUSE LANE
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968
Practice Address - Country:US
Practice Address - Phone:631-726-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-09
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025598363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY025598OtherNEW YORK STATE PHYSICIAN ASSISTANT LICENSE